Ashok Kumar Praharaj

Assessment of non-invasive models for liver fibrosis in chronic hepatitis B virus related liver disease patients in resource limited settings

CONTEXT A total of 350 million individuals are affected by chronic hepatitis B virus infection world-wide. Historically, liver biopsy has been instrumental in adequately assessing patients with chronic liver disease. A number of non-invasive models have been studied world-wide. AIM The aim of this study is to assess the utility of non-invasive mathematical models of liver fibrosis in chronic hepatitis B (CHB). Indian patients in a resource limited setting using routinely performed non-invasive laboratory investigations. SETTINGS AND DESIGN A cross-sectional study carried out at a tertiary care center. SUBJECTS AND METHODS A total of 52 consecutive chronic liver disease patients who underwent percutaneous liver biopsy and 25 healthy controls were enrolled in the study. Routine laboratory investigations included serum aspartate aminotransferase (AST), Alanine aminotransferase (ALT), Gama glutamyl transpeptidase (GGT), total bilirubin, total cholesterol, prothrombin time and platelet count. Three non-invasive models for namely aspartate aminotransferase to platelet ratio index (APRI), Fibrosis 4 (FIB-4) and Forns index were calculated. Outcomes were compared for the assessment of best predictor of fibrosis by calculating the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of each index. STATISTICAL ANALYSIS USED Medcalc online software and by Microsoft Excel Worksheet. Chi-square test was used for significance. P value < 0.05 was taken as significant. RESULTS While the serum levels of AST, ALT and GGT were significantly higher in patients group as compare with the healthy controls (P < 0.01), the platelet counts were significantly lower in patient group as compared to the control group (P < 0.01). Mean value of all 3 indices were significantly higher in patients group as compare with the controls (P < 0.01). CONCLUSIONS Out of the three indices, APRI index with a NPV of 95% appeared to be a better model for excluding significant liver fibrosis while FIB-4 with a PPV of 61% showed fair correlation with significant fibrosis. Thus, these two non-invasive models for predicting of liver fibrosis, namely APRI and FIB-4, can be utilized in combination as screening tools in monitoring of CHB patients, especially in resource limiting settings.

Co-circulation of all four dengue virus serotypes: First report from Odisha

The present report describes the detection of co-circulation of all the four dengue serotypes along with rarely detected dengue viruses (DENVs)-4 for the first time in Odisha. One hundred and forty-eight blood samples were tested for dengue NS1 antigen ELISA and IgM antibody (Ab), and twenty early samples were subjected for type-specific multiplex reverse transcription-polymerase chain reaction (RT-PCR). Twenty-three samples found positive for dengue NS1 and/or IgM Ab; five were positive by RT-PCR. DENV-4 was detected in one sample, DENV-2 in two and 2 were co-infected with DENV-1 and 3. Co-circulation of all four dengue serotypes in Eastern India emphasises the need of molecular monitoring of circulating DENV serotypes.

Burkholderia cepacia pseudobacteremia traced to contaminated antiseptic used for skin antisepsis prior to blood collection

Background: Burkholderia (previously Pseudomonas) cepacia is a Gram-negative bacillus commonly found in soil and moist environments and capable of surviving and growing in nutrient-poor surroundings. It is a problematic pulmonary pathogen in patients with cystic fibrosis and is associated with a poor prognosis. Small hospital outbreaks are frequent, usually because of a single contaminated source such as disinfectant. Aim: To identify the source and route of infection of B. cepacia grown from 12 patients from a surgical ICU. Methods: We carried out an environmental and epidemiological investigation to identify the source and route of infection. Environmental samples previously reported to be potential reservoirs of B. cepacia were collected and processed. Results: Out of 67 blood samples received in a 2-month period from the ICU (surgical) of a tertiary care centre, B. cepacia was isolated from blood specimens of 12 patients, whereas 34 samples grew organisms other than B. Cepacia, 20 specimens were culture negative. There were no cases of B. Cepacia in the last 1 year before this outbreak. We isolated B. cepacia from the cetrimide + chlorhexidine solution used for skin antisepsis prior to blood collection. Conclusion: B. cepacia has the potential to cause fatal infections and its multidrug resistance makes its presence dangerous in hospital settings. The surveillance of B. cepacia infections should not be neglected, especially in the ICUs. Given the high transmissibility of the microorganism and previous epidemic reports, strict infection control measures should be applied in the case of diagnosis of B. cepacia infection.

Distribution of hepatitis B virus genotype and cancer predicting precore and basal core promoter mutations

BACKGROUND Chronic hepatitis B (CHB) infection which is associated with an increased risk of developing liver disease including cirrhosis and hepatocellular carcinoma. Viral factors that may increase the risk for HCC development include HBV DNA level, genotypes, and naturally occurring mutations such as hepatitis B virus precore (PC) (G1896A) and basal core promoter (BCP) A1762T/G1764A double mutations. HBV genotypes and subgenotypes can significantly influence HBeAg seroconversion rates, viremia levels, mutational patterns that could significantly influence the heterogeneity in clinical manifestations and even response to antiviral therapy. METHOD 94 CHB infected individuals with detectable serum HBV DNA levels were studied. HBsAg, HBeAg, anti-HBc IgM antibody estimations were done by ELISA. HBV DNA estimation was done. The HBV genotypes were determined by TSP-PCR and 10 samples randomly selected for DNA sequencing. PC and BCP mutations were determined by DNA sequence analysis of core region. RESULT Of 94 study participant samples with detectable serum HBV DNA levels, 75 were successfully genotyped and sequenced for BCP/PC region. 30/75 (40%) harbored PC and BCP mutations. The total Double mutations of BCP at A1762T/G1764A nucleotide positions, and PC mutation at G1896A nucleotide position were seen in 29.3% and 21.3%, respectively. All 75 isolates were subtype D using TSP-PCR. However, by sequencing 2/10 were subtype A, while 8 were subtype D. CONCLUSION Our study reinforces that D is the predominant genotype in Indian population. It reveals that Indian CHB subjects have increased prevalence of BCP & PC mutations, which possibly may lead to development of HCC.

Emergence of VIM-2 metallo-beta-lactamase producing Ralstonia pickettii clinical isolate in India

A multidrug-resistant clinical isolate of Ralstonia pickettii from a woman was analysed. Modified Hodge test was positive for carbapenemase production. Conjugation experiment revealed the presence of conjugative plasmid of >140 Kb size typed as IncN type. This is the first report of emergence blaVIM-2 in R. pickettii in India.

Assessment of T-Cell Immunoregulatory Cytokine Patterns for Liver Fibrosis in Chronic Hepatitis B Patients Before and After Interferon Therapy

Many of the chronic hepatitis B patients have a higher risk of developing liver disease, such as cirrhosis and/or hepatocellular carcinoma. Cytokines play an important role in the host response to hepatitis B virus (HBV) infection. Present study was planned to assess the T-cell immunoregulatory cytokine patterns in chronic hepatitis B patients & correlate them in response to interferon therapy. Study comprised of two groups. Group A included 25 treatment naive chronic hepatitis B patients. Group B included 25 chronic hepatitis B patients who had received 4 to 6 months of peg interferon treatment. Control group included 25 apparently healthy individuals. Assessment of cytokines was done by quantitative type of sandwich ELISA. Pre and post treatment viral load was determined by real time PCR. HBeAg was done by ELISA. HBV DNA levels in group A patients was 1.4 x 107 copies/ml, and HBeAg positivity was 18/25. HBV DNA levels in group B patients were 5.2 x 105 copies/ml, and HBeAg positivity was 08/25. When compared to cytokine patterns, TH2 associated cytokines were significantly higher in group A patients (P<0.01), and TH1 associated cytokines were significantly higher in group B patients. Interferon therapy might be effective in decreasing the viral burden, and in turn may delay the progression of chronic liver disease. Out of the four cytokines assessed, IL-18, and IL-4 can be used as a marker of response to Interferon therapy.

A case of chronic lacrimal canaliculitis: revisiting the role of Actinomyces israelii

Chronic suppurative lacrimal canaliculitis is an important cause of ocular surface discomfort. Being a relatively rare condition, it is commonly overlooked and undiagnosed for long periods of time. Actinomyces israelii is classically cited as the most common causative organism of canaliculitis,1 at the same time, isolation is difficult owing to the anaerobic nature of the pathogen. Herein we present a case of chronic lacrimal canaliculitis successfully managed with the therapeutic triad of surgery, systemic antibiotics, and topical eye drops to increase awareness for this treatable condition. A 75-year-old male, retired personnel, presented with complaints of swelling at medial canthus of the left eye of one-year duration associated with pain, ocular discharge, redness, and watering. Prior to his visit at our hospital, he had consulted another hospital and received certain medications for his symptoms, but without relief. He was a known diabetic since 10 years, on oral glucose lowering agents and had primary open angle glaucoma. There was no history of trauma, or ocular surgery within the past six months. Ocular examination revealed swelling near left punctum associated with pouting of punctum with yellowish whitish material (sulfur granules) blocking the punctum. A Gram stain of the sulfur granules showed, Gram positive, non-acid fast, branching filaments, suggestive of Actinomyces species (Fig. 1A). Anaerobic culture

Staining of hydatid elements: a useful adjunct in the diagnosis of hydatid disease

Staining techniques have immeasurably aided diagnosis of hydatid disease on several instances. The use of staining techniques for their ability to aid in the morphological diagnosis of hydatid elements, especially at rare and uncommon sites, is discussed.